Last year before the lockdown during a brief visit to Benin I visited a close friend, colleague and former classmate at the University Of Benin Teaching Hospital. She is a Deputy Director at the hospital and unit head at the Paediatrics Pharmacy Unit. One of the many things we talked about was the evolution of Clinical Pharmacy practice and inpatient Pharmaceutical care management. She spoke so passionately about her pediatrics unit and displayed a vast knowledge of drug therapy management in various pediatric conditions and then she expressed a need. She wished there is a specialty course in Pediatric Pharmaceutical care she could attend. I was so proud of her passion for Pediatric Pharmaceutical care. I recomended she check with one of the special centers between College of Medicine and Faculty of Pharmacy UNIBEN maybe they might point her in the right direction. Though I had never heard of any in Nigeria she may eventually need to do the certification online or abroad.

Pediatric Pharmaceutical care is a Clinical Pharmacy specialty that basicaly narrows down medication therapy management to specific age range of 0 to 12 years. Opara 2020 et al'., describes it as Pharmaceutical care in a heterogenous group with infants ageing from birth to 1 year and Children 1 to 12 years, and also includes neonates ageing from birth to 4 weeks and preterm babies. It is the provision of drug therapy (Pharmacotherapy) management to this specific age group based on their anatomical and physiologic peculiarities (age, body mass, organs at various stages of development and maturity, disease condition, genetic predisposition, pharmacodynamics and intersubject variability) with the ultimate purpose of achieving definite outcomes that improve quality of life. In plain English "you dont manage drug therapy for children the same way you manage for adults"

It explores dosage administrations and routes of administration based or peculiarities and disease conditions in children at various developmental stages.

Pediatric Pharmaceutical care is necessary because though studies show that Nigeria has ample supply of medications for primary care use, there is a deficiency of pediatric dosage forms for prescription only medications used for secondary and tetiary care. Consequently extemporanous reconstitution of prescribed medicines in the Pharmacy becomes necessary. Recostitution of pediatric medications is a highly sensitive but commonly overlooked area. Hospitals which take it seriously have had to locate a Pediatric Pharmaceutical Care unit within the Special Care Baby Unit (SCBU) and/or the Paediatrics Unit.

The American Society of Health-System
Pharmacists and the Pediatric Pharmacy Advocacy Group in 2018 published a gudeline titled "ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems" to guide Clinical Pharmacists in meeting the special needs of the pediatric population. This underscores the importance of Pediatric Pharmaceutical Care as a specialty in Hospital Pharmacy practice. This is because studies show the pediatric population is a more vulnerable group to Adverse Drug Reactions (ADRs) than the adult population, exhibit higher variability in Pharmacokinetic and pharmacodynamic profiles of drugs and have pharmacogenetic variations such as Glucose-6-phosphate dehydrogenase(G6PD) deficiency, short gut syndrome and lactose intolerance. There is also a lesser tendency for recipients to report ADRs either because they are too young to recognise the injury(children), are too young to communicate (Babies) or are not being monitored by a vigilant caregiver. Pediatric Pharmaceutical care specialty is important because many drugs that are safe for adults are not safe for children.

There is even the school of thought which intends to include unborn children in pediatric pharmaceutical care by trying to prevent genetic anomalies or irreversible damage to the unborn baby as a result of substances consumed by the mother during pregnancy. For example, an eight month pregnant mother taking Tetracycline capsules as antibiotic treatment for her infective cough will likely cause bone distortion in the child as a result of calcium/phosphorus chelation and Dental dysplasia (brownish/yellow coloring of teeth). There is neonatal death due to chloramohenicol induced "grey baby" syndrome and Kernicterus from taking Sulphonamides. So should this be included in paediatric pharmaceutical care or left to the OBGYN?

A recent study by Tareq 2017' et al'., insists that Pharmacists must have a baseline knowledge of Pharmaceutical care in pediatrics not only for the purpose of councelling care givers but also for dosage form reconstitution and inpatient interventions to correct medication errors that could result in ADRs (Adverse Drug Reactions) or suboptimal dosing.

For example, at the National Hospital Abuja in Nigerias Federal Capital Territory the Pediatric Pharmacy unit is tasked with the responsibility of carrying out interventions. The Clinical Pharmacists :

1. - recomend dose adjustments where necessary,
2. - proactively intercept medication errors during prescription review and revert back to prescriber, (dosage calculation errors are known to be the most common sources of medication error)
3. - Track patient adherence and persistence,
4. - identify drug therapy problems based on known classifications, and
5. - take appropriate action where necessary
6. - educate parents and children themselves.

In all these clinical pharmacokinetic parameters such as age, weight, Body Mass Index(BMI), Renal function, Cardiovascular impairments, Drug elimination rates, Bioavailability, Volume of Distribution etc are considered. The pharmacist actually takes a wholistic picture of the situation and arrives at a care plan which will also involve the patients parents or care givers upon discharge. This is all done in collaboration with the entire inpatient management team at the hospital. Nurses are very fond of crosschecking and reviewing medication administration plans with the pharmacist and it is not uncommon for them to frequently seek clarification for routes and modes of administration. Post discharge the parents or caregivers also maintain close collaboration with the pharmacists and report on progress and any unwanted effects observed. Communication is maintained effectively via phone and wattsap chats which also enable sending photos and screen shots as visual aids.

In Pediatric Pharmaceutical care one thing is most improtant, VIGILANCE. Its simple, the Pharmacist must remain vigilant in prescription review, extemporaneous preparation or precribed medication reconstitution, medication administration, patient/care giver counceling and ADR monitoring. Hence Pharmacovigilance within the pediatric inpatient unit takes a different dimension. The Pharmacist is aware of common drug related problems identified with specific medicines and takes measures to look out for them.

Pharmacists should realise that after discharge and the patient becomes an outpatient the larger burden subsequently lies on the pharmacist who will be frequently contacted by the childs caregivers for clarification on various drug related issues.

Picture this : For a drug like Digoxin the optimal dose for a Baby may instantly kill an adult. We all observe that children are prescribed lower doses than adults. But do you know that children actually require higher drug doses than adults? Doses are determined on a milligram per kilogram (mg/kg) body weight basis. Anyways, that is a story for another day.

Let me know your thoughts by droping your comments below. As men of honour………!

References :

American Society of Health-System
Pharmacists, Inc., and the Pediatric Pharmacy Advocacy Group, 2018, ASHP–PPAG guidelines for providing pediatric pharmacy services in hospitals and health psystems. Am J Health-Syst Pharm. 2018; 75:1151–65.

DIGOXIN Pediatric Monographs, 2021, Copyright 2021, Medical Security Card Company, LLC, dowloaded at https://www.wellrx.com/digoxin/pediactric-monographs/ on 16th January 2021.

Enato E, 2020, lecture notes, Sukthankar V, Individualization of dosage regimen, Clinical Pharmacokinetics, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Moles.R, Carter. S, 2028, Pharmaceutical Care in Pediatrics, Springer Link, downloaded at https://link.springer.com/chapter/10.1007/978-3-319-92576-9_31. on 16th January 2021.

Opara A, 2020, lecture notes in Pediatric Pharmaceutical care, Pharmaceutical care, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Tareq L. Mukattash, Anan S. Jarab, […], and James C. McElnay, Pharmaceutical Care in Children, Sultan Qaboos University Medical Journal, downloaded at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443271/ on 16th January 2021.

The post WHY DOES SHE LIKE THE PEDIATRIC PHARMACEUTICAL CARE SPECIALTY. first appeared on CPAN WORLD.

By Pharm Nathan Ohiomokhare

A child first learns to avoid a candle light or hot lantern because it burnt him/her. Subsequently the child will literaly run away from any bright object, especially one that emits heat. The brain has a very strong Adrenergic system which registers sources of danger and will activate fear and apprehension as soon as such a signal is identified. The same effect is imparted by an Adverse drug reaction. The same goes for the Covid-19 vaccine.

As people all over the world start receiving shots of the vaccine they are beginning to realize that there are adverse reactions related to administering the vaccine. It is not the reactions that may be the problem, it's that they were not fore-warned, they did not know, they were not informed. Consequently they go and tell their family and friends. There have been reports of fainting, itching, redness at the area if inoculation, and even death. I once fainted when I was about 14 years old after my nurse administered a shot of the highly potent antipyretic Nolvagin (metamizol) to bring down my malaria fever. This was because the drug is a chemoreceptor trigger and caused me to vomit and suddenly lose energy.

Adverse drug reactions (ADR) are described as untoward, undesirable or unwanted effects observed by a patient during or after a medication has been administered or taken. They cause discomfort of various degrees and may cause injuries that are reversible or permanent. Many ADRs are life threatening and require emergency care in the ICU of a Hospital facility. ADRs are particularly popular amongst healthcare experts because they represent a major source of discomfort to the patients and the major reason the patient will stop taking the medication or be reluctant to take the medication in the first place. Thus ADRs affect patient compliance, adherence and persistence tremendously. 

 

Compliance is the ability of the patient to follow instructions on how to take the medication and other lifestyle modifications to support the medication therapy. Adherence is the patients willingness co-operate and collaborate with the healthcare provider on the guideline and play an integral role in his/her medication therapy. Though compliance and adherence are used interchangeably compliance is more instruction based which adherence is more of a collaboration. Persistence is the patient's ability to continue with medication therapy for the entire duration of treatment. For the purpose of discussing Covid-19 related ADRs I have simplified these definitions and narrowed their use. 

 

The interesting thing about ADRs is that they are not entirely the fault of the drug alone. The fault actually goes around or extends as follows;

 

·         It's the Drugs fault - if the drug was not compatible with the patients physiology or genetics.

·         It's the patients fault - If he or she failed to communicate any underlying condition, any other medication being taken, any other fruit or supplement being taken, any unusual food being taken. (Underlying conditions refer to illness/disease or disability - hypertension, Diabetes, kidney disease, Imunocompromised, genetic disease, etc )

·         It's the patients fault- if he or she fails to take the medication as advised (non compliance) is argumentative and uncooperative on how to take the medication (non adherence) or is  lazy about taking the medication for the length of time desired (lacks persistence).

·         It's the Healthcare providers fault - if he or she fails to advise properly on the proper mode of administration resulting in over dosage or under dosage (prescription error).

·         It's the Healthcare providers fault - if he or she fails to advise properly on what to avoid while using the medication.

·         It's the Healthcare providers fault - if he or she fails to put into consideration any underlying medical condition(s) (co-morbidities) the patient might have.

·          

Just last month a video was shared in one of my professional groups on Wattsap where a nurse who was the first to receive the Pfizer/Biontech Covid-19 Vaccine fainted on live TV shortly after receiving the vaccine. Later, news circulated that she claimed to suffer from a fainting condition, which was not listed in her medical history. Another recent story which is currently circulating is of a lady who lost the love of her life due to an ADR after taking the Covid-19 Vaccine. 

 

According to her very touching story "her husband Gregory Michael MD an Obstetrician with Mount Sinai Medical Centre (MSMC) in Miami Beach died due to a strong reaction to the COVID vaccine. He was a very healthy 56 year old, loved by everyone in the community delivered hundreds of healthy babies and worked tirelessly through the pandemic." Gregory was said to have been vaccinated at MSMC on December 18, 3 days later he observed a strong set of petechiae on his feet and hands which made him seek attention at the emergency room at MSMC. The Full Blood Count (FBC) done on arrival showed his platelet count to be 0 (A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood.) he was admitted in the ICU with a diagnosis of acute Immune Thrombocytopenia caused by a reaction to the COVID vaccine. A team of expert doctors tried for 2 weeks to raise his platelet count to no avail. 2 days before a last resort surgery,  he had a hemorrhagic stroke caused by the lack of platelets that took his life in a matter of minutes. Gregory was said to be a pro vaccine advocate that is why he took the vaccine himself.''

 

Clinical Pharmacists role in advising and informing about potential Adverse Drug Reactions seem to have been underplayed here. Are the Pharmacists not being involved in Vaccine administration?

 

As the Federal government of Nigeria begins to roll out Vaccine supplies nationwide patient medication education on potential adverse drug reactions should be put at the forefront. And Pharmacists should be actively engaged to provide that information. There is not better placed professional on the planet trained to provide services in this role than a Pharmacist. While other professionals wait to hear of the adverse reactions experienced by other patients in other climes before understanding cause and effect relationships, Clinical Pharmacists are already trained in a unique position to foresee, predict, inform the patient and educate other professionals on what to expect and what actions to take should an Adverse Reaction Occur. 

 

The Covid-19 Vaccine program stands a risk of losing momentum due to negative publicity caused by ADRs. The Covid-19 Vaccine program in Nigeria cannot afford to wait for rumours or stories from the west about ADRs. A more proactive approach is needed otherwise vaccine uptake by the populace will be truncated as people begin to lose confidence in the vaccine due to bad press and negative publicity.  Pharmacists Drug Information Services are a structure already in place to carry out this sensitive role. Facilities lacking proper drug information units manned by a Pharmacist should be adequately equipped and staffed to share such information with the necessary authorities and carry out intervention where necessary. The NAFDAC yellow form for reporting ADRs are in the custody of the Pharmacists who are uniquely qualified to investigate and fill such forms to make reports to NAFDAC. 

 

Pharmacists counseling prior to vaccine administration is a way of giving the client a "heads up" on potential reactions that may be observed while receiving the Vaccine or after receiving the vaccine. Medication counseling is a form of full disclosure of the risks (major and minor) if any, inherent in taking the Vaccine and is a legal obligation of every healthcare expert.  

 

These points are meant to generate discussions and thought amongst the Healthcare provider community. Your comments will be treated with love.

The post FULL DISCLOSURE : EDUCATING THE PUBLIC ON THE COVID VACCINE AND ADRs first appeared on CPAN WORLD.